Intraoperative hypotension during critical phases of liver transplantation and its impact on acute kidney injury: a retrospective cohort study
Hipotensão intraoperatória durante fases críticas do transplante de fígado e seu impacto na lesão renal aguda: um estudo de coorte retrospectivo
Matthanja Bieze, Amir Zabida, Eduarda Schutz Martinelli, Rebecca Caragata, Stella Wang, Jo Carroll, Markus Selzner, Stuart McCluskey
Abstract
Introduction
Acute Kidney Injury (AKI) following Liver Transplantation (LT) is associated with prolonged ICU and hospital stay, increased risk of chronic renal disease, and decreased graft survival. Intraoperative hypotension is a modifiable risk factor associated with postoperative AKI. We aimed to determine in which phase of LT hypotension has the strongest association with AKI: the anhepatic or neohepatic phase.
Methods
This retrospective cohort study included adult patients undergoing LT between January 2010 and June 2022. Exclusion criteria were re-do or combined transplantations, preoperative dialysis, and early graft failure or death. Primary outcome was AKI as defined by KDIGO. Hypotension was Mean Arterial Pressure (MAP) below predefined thresholds in minutes. Risk adjusted logistic regression analysis considered hypotension in 3 periods: the total procedure, anhepatic phase, and neohepatic phase.
Results
Our cohort included 1153 patients. The median MELD-NA score was 19 (IQR 11–28), and 412 (35.9%) were living-related donations. AKI occurred in 544 patients (47.2%). The unadjusted model showed an association with AKI for MAP < 60 mmHg (OR = 1.011 [1.0, 1.022], p = 0.047) and MAP < 55 mmHg (OR = 1.023 [1.002, 1.047], p = 0.04) in the anhepatic phase, and for MAP < 60 mmHg (OR = 1.032 [1.01, 1.056], p = 0.006) in the neohepatic phase. The adjusted model did not reach significance in the subgroups but did in the total procedure: MAP < 60 mmHg (OR = 1.005 [1.002, 1.008], p < 0.001) and MAP < 55 mmHg (OR = 1.008 [1.003–1.013], p = 0.004).
Conclusion
Intraoperative hypotension is independently associated with AKI following LT. This association is seen during the anhepatic phase. Maintaining MAP above 60 mmHg may improve kidney function after LT.
Keywords
Resumo
Introdução
A lesão renal aguda (LRA) após transplante de fígado (TF) está associada a internação prolongada na UTI e no hospital, aumento do risco de doença renal crônica e diminuição da sobrevida do enxerto. A hipotensão intraoperatória é um fator de risco modificável associado à LRA pós-operatória. Nosso objetivo foi determinar em qual fase da hipotensão do TF tem a associação mais forte com LRA: a fase anepática ou neo-hepática.
Método
Este estudo de coorte retrospectivo incluiu pacientes adultos submetidos a TF entre janeiro de 2010 e junho de 2022. Os critérios de exclusão foram transplantes repetidos ou combinados, diálise pré-operatória e falha precoce do enxerto ou morte. O desfecho primário foi LRA conforme definido pelo KDIGO. A hipotensão foi a pressão arterial média (PAM) abaixo dos limites predefinidos em minutos. A análise de regressão logística ajustada ao risco considerou a hipotensão em 3 períodos: o procedimento total, a fase anepática e a fase neo-hepática.
Resultados
Nossa coorte incluiu 1153 pacientes. A pontuação mediana MELD-NA foi 19 [IQR 11–28], e 412 (35,9%) foram doações relacionadas a vivos. LRA ocorreu em 544 pacientes (47,2%). O modelo não ajustado mostrou associação com LRA para PAM < 60 mmHg (OR1,011 (1,0, 1,022), p = 0,047) e PAM < 55 mmHg (OR 1,023 (1,002, 1,047), p = 0,04) na fase anepática, e para PAM < 60 mmHg (OR 1,032 (1,01, 1,056), p = 0,006) na fase neo-hepática. O modelo ajustado não atingiu significância nos subgrupos, mas atingiu no procedimento total: PAM < 60 mmHg (OR 1,005 (1,002, 1,008) p < 0,001) e PAM < 55 mmHg (OR1,008 (1,003–1,013), p = 0,004);
Conclusão
A hipotensão intraoperatória está independentemente associada à LRA após TF. Essa associação é vista durante a fase anepática. Manter a PAM acima de 60 mmHg pode melhorar a função renal após TF.
Palavras-chave
References
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Submitted date:
09/04/2024
Accepted date:
10/02/2024
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